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TRAVELERSJ'� <br />ONE TOWER SQUARE <br />HARTFORD CT 06183 <br />WORKERS COMPENSATION <br />AND <br />EMPLOYERS LIABILITY INSURANCE POLICY <br />ENDORSEMENT WC 99 03 F3 (00) <br />POLICY NUMBER: Ua—OR34080A-20-42—G <br />CALIFORNIA LIMITS OF LIABILITY ENDORSEMENT <br />This endorsement applies only to the insurance provided by the policy because California is shown in Item <br />3.A. of the Information Page. <br />The limits of our liability under Part Two of the policy are: <br />Bodily Injury by Accident $1,000,000 or the amount shown in Item 3.13. of the Information <br />Page, whichever is greater, each accident <br />Bodily Injury by Disease $1,000,000 or the amount shown in Item 3.6. of the Information <br />Page, whichever is greater, policy limit <br />Bodily Injury by Disease $1,000,000 or the amount shown in Item 3.B. of the Information <br />Page, whichever is greater, each employee <br />This change applies to the insurance this policy provides for California operations only. <br />This endorsement changes the policy to which it is attached and is effective on the date issued unless <br />otherwise stated. <br />(The information below is required only when this endorsement is issued subsequent to <br />preparation of the policy.) <br />Endorsement Effective Policy No. Endorsement No. <br />Insured Premium $ <br />Insurance Company Countersigned by <br />DATE OF ISSUE: 05-11-20 ST ASSIGN: <br />2 Risk MeagemadDMsm <br />eRt Ewm & pAPPROVm aY <br />r'�YNMQ I\. VauNiKC ; <br />Risk Management Maly t w <br />�F <br />